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　　The Associate Director, Utilization Management Nursing utilizes clinical nursing skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations. The Associate Director, Utilization Management Nursing requires a solid understanding of how organization capabilities interrelate across department(s).

　　Overview:

　　The Associate Director, Utilization Management uses clinical knowledge, communication skills, and independent critical thinking skills towards interpreting criteria, policies, and procedures to provide the best and most appropriate treatment, care or services for members. This role is dedicated full-time to the Indiana Pathways program.

　　Position Responsibilities:

　　Serve as a liaison between Humana and the State regarding Prior Authorization reviews, prepayment retrospective reviews, and any additional utilization management functions.

　　Coordinates with Clinical Leadership team to ensure all utilization reviews are in compliance with the terms of the Contract.

　　Responsible for directing the activities and performance of the utilization management staff; direct performance regarding prior authorization, medical necessity determinations, concurrent review, retrospective review, appropriate utilization of health care services, continuity of care, and other clinical and medical management programs.

　　Partner with the Special Investigation Unit (SIU) Manager to assure that service guidance to utilization management staff, prior authorization team members ensuring that the service provided meets or exceeds clinical and procedural and FSSA standards.

　　Ensure adoption and consistent application of appropriate medical necessity criteria.

　　Monitor, analyze, and implement appropriate interventions based on utilization data, including identifying and correcting over- or under-utilization of services.

　　Assure that prior authorization functions and decisions are made in a timely and consistent manner based on clinical criteria and meet timeliness standards to ensure appropriate Notice of Action is followed including collaboration with the Medical Director to ensure reason for denial, reduction, or termination is specific and clear.

　　Develop and implement departmental policies and procedures in accordance with contract changes and/or updates.

　　Maintain compliance with FSSA and the Centers for Medicare and Medicaid Services (CMS) guidelines and contractual requirements.

　　Use your skills to make an impact

　　Required Qualifications

　　Unrestricted Indiana licensed Registered Nurse (RN)

　　5 years Utilization Management Experience such as Prior Authorization reviews, prepayment retrospective reviews, and any additional utilization management functions.

　　Prior experience working with Medicaid and or Medicare programs, such as LTSS or DSNP

　　2 years of management experience with direct reports

　　Comprehensive knowledge of Microsoft Office applications including Word, Excel, and Outlook.

　　Knowledge of Medicaid regulatory requirements and National Committee for Quality Assurance (NCQA) standards

　　Must reside in Indianapolis, IN area and report to the office 3 days a week and be available to travel 10% as needed to attend team meetings or other market meetings.

　　Preferred Qualifications

　　BSN, bachelor's degree in health services, healthcare administration, or business administrationWork-At-Home Requirements

　　To ensure Home or Hybrid Home/Office associates' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria:

　　At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested

　　Satellite, cellular and microwave connection can be used only if approved by leadership

　　Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.

　　Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.

　　Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

　　Interview Format

　　As part of our hiring process, we will be using an exciting interviewing technology provided by Modern Hire, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.

　　If you are selected to move forward from your application prescreen, you will receive an email correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. (please be sure to check your spam or junk folders often to ensure communication isn't missed) If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.

　　If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone to answer the questions provided. Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.

　　Additional Information

　　According to the Indiana Office of Inspector General Rule, 42 IAC 1-5-14 Post-Employment Restrictions, if you are a current or former state officer, employee or special state appointee with Indiana Family and Social Services Administration (FSSA) within the past year, engaged in the negotiation or the administration of a Medicaid contract on behalf of the state and/or Family and Social Services Administration (FSSA); in a position to make discretionary decision affecting the: (1) outcome of the negotiation; or (2) nature of the administration; or either engaged in making a regulatory or licensing decision that directly applied to Humana Inc. or to a parent or subsidiary you cannot be considered for this opportunity.

　　For more information please visit: IG: Indiana Office of Inspector General (https://www.in.gov/ig/)

　　Scheduled Weekly Hours

　　40

　　About us

　　Humana Inc. (NYSE: HUM) is committed to putting health first - for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health - delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.

　　Equal Opportunity Employer

　　It is the policy of  Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or because he or she is a protected veteran. It is also the policy of  Humana to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.

　　Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https://www.humana.com/legal/accessibility-resources?source=Humana_Website.